Month: February 2015

Webster’s Dictionary (1974) defines resilience as “an ability to recover from or adjust easily to change or misfortune” (p. 596). Although this definition is widely accepted, resilience may be conceptualized as being more than merely bouncing back from setbacks. Resilience may also be the ability to bounce forward in the face of an uncertain future (Walsh, 2004). Resilience has been conceptualized as the forging of strengths through adversity (Wolin & Wolin, 1993). Like the willow tree, people thrive if they have a strong, healthy root system. With branches flexible enough to bend with the storm and firm enough to weather strong winds without breaking, the willow tree can continue to grow despite being twisted into differing shapes. The willow tree may be a metaphor for the resilient individual and resilient family system. Resiliency is critical to mental health and healthy aging.

Bonanno (2004) defined adult resilience as a person’s capacity to resist maladaptation in the face of risky experiences. Bonanno’s individually-based definition of adult resilience assumes that resilience resides in the person, an observation supported by the list of individual attributes that covary with resilient outcomes in Bonanno’s work (hardiness, self-enhancement, repressive coping, and positive emotion.). Importantly, this definition of resilience does not identify the positive outcomes that can result from adversity in the hardy individual. Despite Bonanno’s (2004) narrow definition, his analysis includes an interesting finding that loss and brief traumatic experiences, despite being aversive and difficult to accept, are normatively not sufficient to overwhelm the adaptive resources of ordinary adults. Bonanno’s research calls into question the research of Sameroff, Bartko, Baldwin, Baldwin, and Seifer (1998), which demonstrated in longitudinal analyses that as levels of adversity rise, and as resources fall, resilience becomes less tenable.

Rutter (1985) observed that strong self-esteem and self-efficacy make successful coping more likely, whereas a sense of helplessness increases the likelihood that one crisis will lead to another. In a similar vein, Kobasa’s (1985) research findings supported his hypothesis that people with resilience possess three general traits: (1.) the belief that they can influence or control events in their lives; (2.) an ability to feel deeply committed and involved in activities in their lives; and (3.) a tendency to embrace change as an opportunity to grow and develop more fully. Thus, resilient children are more likely to have an inner locus of control (Seligman, 1990), or an optimistic belief that they can positively impact their fate.

Dugan and Coles (1989) suggest that individuals prevail over adversity more effectively if they have moral and spiritual resources. In a phenomenological study of nine subjects who had experienced such traumas as life in a concentration camp, disability, breast cancer, massive head injury, a life of violence and abuse, and loss of a child, Rose (1997) identified similar themes of resilience which emerged from individual interviews: the role of supportive others, empathy, self-care, faith, action orientation, moving on, positive outlook, and persistence. Rose identifies the foundational structure of resilience as faith, self-respect, striving, supportive others, coping, empathy, self-reliance, and moving on.

Closer scrutiny of children and families that are at risk reveals many exceptions to the “damage model” of development, which considers stress or disadvantage as predictive of dysfunction. For example, Werner and Smith (1992) conducted an extensive longitudinal study of almost a half a century of children from Kuai. The researchers found that in spite of early medical distress, poverty, school difficulties, teen pregnancy, or arrest, children were able to learn and persevere through difficulty, given adequate supports. In their analysis of how these impoverished children matured successfully, Vaillant (2002) notes that Werner and Smith emphasized, “. . . the importance of being a ‘cuddly’ child and of being a child who elicits predominantly positive responses from the environment and who manifests great skill at recruiting substitute parents” (p. 285). Werner and Smith point out that key turning points for most of these troubled individuals were meeting a caring friend and marrying an accepting spouse. It is also salient that Werner and Smith found that more girls than boys overcame adversity at all age levels. Walsh (2004) speculates that this finding reflects the notion that “. . . girls are raised to be both more easygoing and more relationally-oriented, whereas boys are taught to be tough and self-reliant through life. . . [and] often because of troubled family lives, competencies were built when early responsibilities were assumed for household tasks and care of younger siblings” (pp. 13-14). Werner and Smith’s study is especially important in reminding clinicians that early life experiences do not necessarily guarantee significant problems in later life. Walsh (2004) suggests that their most significant finding is that resilience can be developed at any point over the course of the life cycle. Walsh extrapolates from Werner and Smith’s research that “. . . unexpected events and new relationships can disrupt a negative chain and catalyze new growth” (p. 14). Favorable interactions with individuals, families and their environments have a systemic effect of moving resilience in upward spirals, and a downward spiral can be reversed at any time in life (Walsh, 2004).

Felsman and Vaillant (1987) followed the lives of 75 males living in impoverished, socially disadvantaged families. People who suffered from substance abuse, mental illness, crime and violence parented these men. Several of these men, although scarred by their childhoods, lived brave lives and became high functioning adults. Felsman and Vaillant concluded, “The events that go wrong in our lives do not forever damn us” (1987, p. 298).

Another study refuting the accuracy of the “damage model” is Kaufman and Zigler’s (1987) finding that most survivors of childhood abuse do not go on to abuse their own children. Similarly, other research found that children of mentally ill parents or dysfunctional families have been able to prevail over early experiences of abuse or neglect to lead productive lives (Anthony, 1987; Cohler, 1987; Garmezy, 1987).

Werner (1995) identified clusters of protective factors that have emerged as recurrent themes in the lives of children who overcame great odds. The protective factors that were characteristic of the individual were myriad. Resilient youngsters are engaging to other people. Additionally, they excel in problem-solving skills and display effective communication skills. Problem solving skills included the ability to recruit substitute caregivers. Moreover, they have a talent or hobby valued by their elders or peers. Finally, they have faith that their own actions can make a positive difference in their lives.
From a developmental perspective, Werner (1995) emphasizes that having affectional ties that encourage trust, autonomy, and initiative enhances resilience. Members of the extended family or support systems in the community frequently provide these ties. These support systems reinforce and reward the competencies of resilient children and provide them with positive role models. Such supports may include caring neighbors, clergy, teachers, and peers.

In Vaillant’s (2002) Study of Adult Development at Harvard University, arguably the longest longitudinal study on aging in the world, it is suggested that resiliency researchers who focus on risk factors and pathology are mistaken in believing that misfortune condemns disadvantaged children to bleak futures. Instead, Vaillant calls upon clinicians to count up the positive and the protective factors when conducting assessments. Vaillant cites Sir Michael Rutter (1985), who reminds clinicians, “The notion that adverse experiences lead to lasting damage to personality ‘structure’ has very little empirical support” (p. 598).

Vaillant (2002) identifies four protective factors in the individual’s potential to age well. A future orientation, a capacity for gratitude and forgiveness, a capacity to love and to hold the other empathically, and the desire do things with people instead of to people are personal qualities identified as resiliency factors. He posits that “. . . marriage is not only important to healthy aging, it is often the cornerstone of adult resilience” (p. 291).

Furthermore, Vaillant (2002) describes resilience as being a combination of nature and nurture. Both genes and environment play crucial roles. He explains, “On one hand, our ability to feel safe enough to deploy adaptive defenses like humor and altruism is facilitated by our being among loving friends. On the other hand, our ability to appear so attractive to others that they will love us is very much dependent upon the genetic capacity that made some of us ‘easy’ attractive babies” (p. 285).

An essential part of resilience is “. . . the ability to find the loving and health-giving individuals within one’s social matrix wherever they may be” (Vaillant, 2002, p. 286). Thus, like Werner and Smith (1992), Vaillant’s research identified extended families and friendship networks as key foundations to resilience in the individual and the family system.

American culture glorifies the “rugged individual.” John Wayne, the personification of masculinity and strength, has been adored by generations of Americans as a hero. However, there is an inherent danger in the myth of rugged individualism, which implies that vulnerability and emotional interdependence are weak and dysfunctional (Walsh, 2004). As Felsman and Vaillant (1987) note, “The term ‘invulnerability’ is antithetical to the human condition. . . In bearing witness to the resilient behavior of high-risk children everywhere, a truer effort would be to understand, in form and by degree, the shared human qualities at work” (p. 304). Avoidance of personal suffering and the glorification of stoicism are hallmarks of American culture. Such cultural attitudes are typified by the call to “move on,” to “cheer up,” to get over catastrophic events, to put national and global tragedies behind us, or to rebound (Walsh, 2004). Higgins (1994) notes that struggling well involves experiencing both suffering and courage, effectively processing and working through challenges from intrapersonal and interpersonal perspectives. In Higgin’s study of resilient adults, it became clear that they became stronger because they were severely tested, endured suffering, and developed new strengths as a result of their trials. These adults experienced their lives more deeply and passionately. Walsh (2004) observes that over fifty per cent of the resilient individuals studied by Higgins were therapists. Egeland, B. R., Carlson, E. and Sroufe (1993) offer an alternative approach to thinking about resilience as “. . . a family of processes that scaffold successful adaptation in the context of adversity” (p. 517).

Important research conducted by Wolin and Wolin (1993) points toward the notion that although some children are born with innate resiliencies, resiliency can be modeled, taught, and increased. They emphasize that persons tend to seek healing from pain instead of holding on to bitterness. The researchers note that the resilient person draws lessons from experience instead of repeating mistakes, and that they maintain openness and spontaneity in their relationships rather than becoming rigid or bitter in interaction. Wolin and Wolin also found that resiliency in individuals is strongly correlated with humor and creativity, as well as mental and physical health. The Wolins identify seven traits of adults who survived a troubled childhood: insight (awareness of dysfunction), independence (distancing self from troubles), relationships (supportive connections with others), initiative (self/other-help actions), creativity (self-expression, transformation), humor (reframing in a less threatening way), and morality (justice and compassion rather than revenge). Traits are viewed as dynamic processes by which resilient individuals adapt to and grow through challenge, rather than static properties that automatically protect the invulnerable. These observations are correlated with empirical studies of resilient children (Baldwin, Baldwin, & Cole, 1990; Bernard, 1991; Garbarino, 1992; Masten, Best, & Garmezy, 1990; Werner & Smith, 1992) and adults (Klohnen, Vandewater, and Young, 1996, Vaillant, 2002).

Walsh (2004) asserts, “In the field of mental health, most clinical theory, training, practice, and research have been overwhelmingly deficit-focused, implicating the family in the cause or maintenance of nearly all problems in individual functioning. Under early psychoanalytic assumptions of destructive maternal bonds, the family came to be seen as a noxious influence. Even the early family systems formulations focused on dysfunctional family processes well in the mid-1980’s” (p. 15).

The popularity of the Adult Children of Alcoholics Movement surged in the late twentieth century and encouraged people to blame their families for their problems. This movement tempted the individual to make excuses for his behavior in terms of his dysfunctional family history instead of looking for family strengths that might help him/her overcome challenge and become stronger. Adult Children of Alcoholics “. . . spend much of their time other-focused, and it is easy for them to become preoccupied with another group member’s problem, take responsibility for it, and avoid the painful job of self-examination and taking responsibility for their own behavior” (Lawson & Lawson, 1998, p. 263).

In contrast to this damage model, the Wolins offered an alternative way to view challenging family backgrounds: a Challenge Model to build resilience, stating that “. . . the capacity for self-repair in adult children of alcoholics taught [them] that strength can emerge from adversity” (p. 15). The Wolins reflect a paradigm shift in recent years, as family systems therapists have started to focus upon a competence-based, strength-oriented approach (Barnard, 1994; Walsh, 1993, 1995a). A family resilience approach builds on recent research, empowering therapists to move away from deficit and focus upon ways that families can be challenged to grow stronger from adversity (Walsh, 2004). From the perspective of the Challenge Model, stressors can become potential springboards for increased competence, as long as the level of stress is not too high (Wolin & Wolin, 1993). Walsh notes, “The Chinese symbol for the word ‘crisis’ is a composite of two pictographs: the symbols for ‘danger’ and ‘opportunity'” (p. 7). Wolin and Wolin (1993) observe that we may not wish for adversity, but the paradox of resilience is that our worst times can also become our best.

It is clear that the extensive research on resilient individuals largely points toward the social nature of resilience. However, most resiliency theory has approached the systemic context of resilience tangentially, in terms of the influence of a single, important person, such as a parent or caregiver (Bowlby, 1988). Looking at resilient family functioning through a systemic lens calls upon the clinician to view individual resilience as being embedded in family process and mutual influence (Walsh, 2004). Walsh suggests that if “. . . researchers and clinicians adopt a broader perspective beyond a dyadic bond and early relationships, [they] become aware that resilience is woven in a web of relationships and experiences over the course of the life cycle and across the generations” (p. 12).

It has only been in the last twenty five years or so that families that cope well under stress have been the subject of research (Stinnet & DeFrain, 1985; Stinnett, Knorr, DeFrain, & Rowe, 1981). A growing body of knowledge has pointed toward the multidimensional nature of family processes that distinguish adaptive family systems from maladaptive family systems (Walsh, 2004). Walsh (2004) defines “family resilience” as “. . . the coping and adaptational processes in the family as a functional unit,” [and adds that]. . . a systems perspective enables us to understand how family processes mediate stress and enable families to surmount crisis and weather prolonged hardship” (p. 14). Strong families create a climate of optimism, resourcefulness, and nurturance which mirrors the traits of resilient individuals (Walsh, 2004). In fact, research on family adaptation and on family strengths suggests the following traits of resilient families: commitment, cohesion, adaptability, communication, spirituality, effective resource management, and coherence (Abbott, et al., 1990; Antonovsky, 1987; Beavers & Hampson, 1990; Moos & Moos, 1976; Olson, Russell, & Sprenkle, 1989; Reiss, 1981; Stinnett, et al., 1982). Walsh observes, “. . . a family resilience lens fundamentally alters our perspective by enabling us to recognize, affirm, and build upon family resources” (Walsh, 2004, p. viii). Rutter’s (1987) research added further confirmation that resilience is fostered in family interactions through a chain of indirect influences that inoculate family members against long-term damage from stressful events. It is essential to consider family resilience as a major variable in a family’s ability to cope and adapt in the face of stress (McCubbin, McCubbin, McCubbin, & Futrell, 1995).

Bennett, Wolin, and Reiss (1988) concluded from their research that children who grew up in alcoholic families that deliberately planned and executed family rituals, valued relationships, and preferred roles were less likely to exhibit behavior or emotional problems. They argue that families with serious problems, such as parental alcoholism, which can still impose control over those parts of family life that are central to the family’s identity, communicate important messages to their children regarding their ability to take control of present and future life events. These messages can determine the extent to which the children are protected from developing future problems, including alcoholism in adolescence and adulthood.

Patterson (1983) asserts that it is only to the extent that stressors interrupt important family processes that children are impacted. However, from a systemic perspective, it is not only the child who is vulnerable or resilient; most salient is how the family system influences eventual adjustment (Walsh, 2004). Even those family members who are not directly touched by a crisis are profoundly affected by the family response, with reverberations for all other relationships (Bowen, 1978). Following from these ideas, it is clear that “Slings and arrows of misfortune strike us all, in varying ways and times over each family’s life course. What distinguishes healthy families is not the absence of problems, but rather their coping and problem-solving abilities” (Walsh, 2004, p. 15).
From an ecological perspective, Rutter (1987) suggests that it is not enough to take into account the sphere of the family as influencing risk and resilience in the individual and family life cycles. He emphasizes that it is also incumbent upon therapists to assess the interplay between families and the political, social, economic, and social climates in which people either thrive or perish. Rutter’s findings suggest that it is insufficient to focus exclusively on bolstering at-risk individuals and families, but there must also be public policy efforts to change the odds against them.
In the twenty first century, it is apparent that the configuration of the family is shifting. Diverse forms of family systems do not inherently damage children (Walsh, 2004). Walsh emphasizes, “It is not family form, but rather family processes, that matter most for healthy functioning and resilience” (p. 16).

One family process that governs how a family responds to a new situation is the way in which shared beliefs shape and reinforce communication patterns (Reiss, 1981). Hadley and his colleagues (1974) found that a disruptive transition or crisis could potentiate a major shift in the family belief system, with both immediate and long-term effects on reorganization and adaptation. Additionally, Carter and McGoldrick (1999) suggest that how a family perceives a stressful situation intersects with legacies of previous crises in the multigenerational system to influence the meaning the family makes of the adversity and its response to it.

Walsh (2004) asserts, “A cluster of two or more concurrent stresses complicates adaptation as family members struggle with competing demands, and emotions can easily spill over into conflict. . . . Over time, a pileup of stressors, losses, and dislocations can overwhelm a family’s coping efforts, contributing to family strife, substance abuse, and emotional or behavioral symptoms of distress (often expressed by children in the family)” (p. 21). Figley (1989) noted that catastrophic events that occur suddenly and without warning can be particularly traumatic. Bowen (1978) suggested that shock wave effects of a trauma might reverberate through the system and extend forward into multiple generations. Thus, Walsh (2004) calls upon therapists to take a systemic approach to intervention in the face of crisis, with interventions that “. . . strengthen key interactional processes that foster healing, recovery, and resilience, enabling the family and its members to integrate the experience and move on with life” (p. 22).

To understand resilience, one must also look through a developmental lens (Carter & McGoldrick, 1999). Neugarten (1976) found that stressful life events are more apt to cause maladaptive functioning when they are unexpected. Also, multiple stressors create cumulative effects, and chronic severe conditions are more likely to affect functioning adversely. However, Cohler (1987) and Vaillant’s (1995) research found that the role of early life experience in determining adult capacity to overcome adversity is less important than was previously believed. Thus, discontinuity and long-term perspectives on the individual and family life cycle point toward the idea that people are constantly “becoming” and have life courses that are flexible and multidetermined (Falicov, 1988). Furthermore, Walsh (2004) suggests that “. . . an adaptation that serves well at one point in development may later not be useful in meeting other challenges” (p. 13). Research has pointed toward a greater risk in vulnerability for boys in childhood and for girls in adolescence (Elder, Caspi, & Nguyen, 1985; Werner & Smith, 1982). All these variables highlight the dynamic nature of resilience over time.

In the field of family therapy, it is incumbent upon researchers and practitioners to recognize that successful treatment depends as much on the resources of the family as on the resources of the individual or the skills of the clinician (Karpel, 1986; Minuchin, 1992). Family processes can influence the aftermath of many traumatic events, reverberating into the course of the lives of people in future generations. Individual resilience must be understood and nurtured in the context of the family and vice-versa. Both immediate crisis and chronic stressors affect the entire family and all its members, posing threats not only to the individual, but also for relational conflict and family breakdown in current and future generations. Family processes may mediate the impact of crisis on all members and their relationships. Protective processes build resilience by promoting recovery and buffering stress. Indeed, healthy family processes influence the effects of present and future crises far into the future (Bowen, 1978; Kerr & Bowen, 1988). Since all families and their members have the potential to become more resilient, family therapists should work to maximize that potential by strengthening key processes within the individual and within the system.

Garbarino, J. (1992). Children and families in the social environment. New York: Aldine deGruyter.

Garmezy, N. (1987). Stress, competence, and development: Continuities in the study of schizophrenic adults, children vulnerable to psychopathology, and the search for stress-resistant children. American Journal of Orthopsychiatry, 57, 159-174.

Hadley, T., Jacob, T., Miliones, J., Caplan, J., & Spitz, D. (1974). The relationship between family developmental crises and the appearance of symptoms in a family member. Family Process, 13, 207-214.

A child’s poor schoolwork may be a cry for help in family relationships. If the family’s request for help is ignored, the school may be left with a refractory educational problem and an angry child who may continue to fail until someone finally gets the message. In most instances, when children fail in school, some form of family therapy is warranted.
The goal of family therapy is to change structures and processes in the family or in its environment so as to relieve existing strains. Family diagnosis based on living systems theory makes it possible to determine whether pathology lies in a family as a whole, in one or more individual members, or in a suprasystein, such as an economically disadvantaged neighborhood or a school with limited resources.

The range of interventions available to families is considerable. The health, mental health, social service, pastoral care, and educational systems all deal with family problems. The field of marriage counseling has specifically focused on one aspect of the family, and family service agencies handle all aspects of the family. For faltering families the marital relationship is the most important locus: marriage counseling or marital couple therapy may be useful. For families with more serious problems, self-help groups such as Alcoholics Anonymous, Parents Without Partners, and Parents Anonymous are available in most communities. Child psychiatrists deal with the range of child, adolescent, and family problems.

The fit between clinical resource and a family is critical. Ethnic and economic factors may override psychological issues. Every clinical resource sets some limit on the range of factors it can work with in both diagnosis and therapy. These limits evolve out of the history peculiar to a given clinical setting, the training backgrounds of professionals, the socioeconomic sur�roundings, and the nature of the social pressures.

Motivating Families for Therapy

Professionals should be sensitive to the misunderstanding, hesitation, and fear in family members as they approach help.

Each family member’s level of sophistication about psychological problems and openness to using a mental health resource varies. At the least education of the mem-bers of the family is required so that an intellectual understanding of the reasons for working with the family can be achieved. This step often is omitted with resulting misunderstandings.

Troubled families are the most likely to lack insight and even the strength to engage in family therapy. Their defensive maneuvers may he so extreme that engaging the family in therapy may depend upon equally skillful maneuvering by the therapist or the external pressure of agencies, such as the schools and the courts. If given a choice, many of these families would either drop out or limit their involvement to supporting treatment of the identified patient. Their denial and projection are particularly difficult to handle.

Ferreting out the family’s expectations of therapy is an important step toward assessing their motivation For change. For example, because dominated families involve both family and individual psychopathology, they often lodge their concerns upon a single identified patient. The other family members may not be disposed to see themselves as a part of that person’s problem and certainly not as the focus of therapy. When an attempt is made to involve the family, the parents may withdraw and look for someone who will “help”. the family member identified as a patient. As a strategy, the therapist may need to appear to join the family in its efforts to change the symptom bearer as a means of involving the entire family with the passage of time.

Conflicted families usually, require intensive family therapy in addition to consultation to other systems. such as the schools, social services, and law enforcement agencies. Chaotic families are the most difficult to engage in family therapy because their views of reality are not congruent with their social milieu. Hospitalization, medication, and consultation to other agencies may be necessary. in order to provide a foundation for family therapy.

A delicate issue in motivating families for treatment is how to separate a clinician’s responsibility to assist the family from the family’s responsibility for change. This is a problem especially when other agencies are involved with the family. For example, both school personnel and parents may look to a clinician for answers about a child. In these circumstances the clinician must carefully keep the child and the family in the position of responsibility and work through them for inter-system negotiations. Unsuccessful management of this issue can make the clinician a scapegoat by permitting both the parents and school personnel to expect that the therapist is responsible for changing the child.

From the educator’s point of view, it is important to he aware of the complicated role of the family in a child’s school problems over which educators and parents find themselves in conflict. Some parents obtain satisfaction from this fight, because they were embittered by their own past unhappy school experience and find this opportunity to retaliate. The child has an especially important role to play in this manipulative struggle. In the battle over who will control the helping process, if the school and clinical team are not coordinated, a family can find a weak link and defeat both. An effective position for school personnel in these situations is to recognize that no one can help the child until everyone works together.

The Techniques of Family Therapy

The theories and techniques employed by family therapists vary. widely. General systems theory, however, provides a rationale for integrating them.

The aims of family therapy are to promote the basic functions of the family. Forming a family unit assists adults in appropriately disengaging from their families of origin. The functions of a family relate to intimacy between family members in the form of attachment bonds and empathic communication, which can be fostered through increasing sensitivity to others and risking exposure of one’s personal vulnerability. As the heart of the socialization process, the family is the vehicle for imparting cultural customs and values through the process of identification and through learning coping skills. The family also is the forum for safely expressing transient irrational emotions and accepting them from others. In the family the irrationality of life can be accepted by acknowledging the differences between the way things should be and the way they are, between expectations and reality, and between verbalizing socially unacceptable emotions and wishes and acting upon them.

The barriers to healthy family functioning are stereotyped roles enacted by family members based upon covert scripts that are incongruent with family functions. Examples of these roles are victim, martyr, hero, tyrant, scapegoat, saint, rebel, fool, and genius. These roles are played out from ritualized scripts that maintain immature, destructive relationships and frustrate the individuation and development family members. Family therapy creates awareness of these counterproductive scripts and roles through confrontation, interpretation, playfulness, and humor in order to foster flexibility in family members within legitimate family roles.

The techniques or family therapy include behavioral, structural, and intuitive methods. The accumulation of clinical experience is demonstrating the usefulness of employing a range of techniques in an integrated style of therapy. The family therapist can assist families to more realistically function by acting as a catalyst who facilitates interaction; a critic who describes behavior; a teacher who shows new ways; a supporter who gives license and hope; an interpreter who offers explanations of behavior; a provocateur who stimulates interaction, and a model who demonstrates solving problems.

Because of its highly structured nature, the Milan method of family therapy has been employed for training purposes. It involves a therapeutic team that helps families through confronting them with more realistic views of their family interactions while encouraging family members to achieve more adaptive levels of relating to each other.

The Process of Family Therapy

Once a family becomes engaged in the therapeutic process, a varied and exciting course of growth may ensue, or the process itself may be impeded by resistance that must be worked through in order to achieve the aims of therapy.

Family members usually have linear cause-and-effect views of what goes on in the family. For example, “Jimmy’s restlessness gets us all upset.” The aim of family therapy is to shift the level of understanding from this simplistic and partially correct view to an interactional system level. An important technique for accomplishing this is through encouraging family members to comment on each other’s relationships in the family. This both opens up communication and focuses attention on interactions within the family.

Through a variety of reframing statements additional information can be given to a family to encourage more accurate interactional and psychodynamic understandings of the determinants of symptoms in family members. For example, the success that a child achieves through failing in school and sabotaging adults can be contrasted with the view of the child’s behavior as simply negative. As a family grapples with a child’s problem. their frustrations and discomforts become evident and permit redefinition of the problem in terms of family members’ personal sufferings rather than the problem child’s behavior. New communication lines ran be opened, so that an awareness of the family’s role in a child’s educational difficulties can add a crucial dimension to helping the child. The family can then realistically support the educational program for their child and assume a parent-professional alliance with school personnel.

Some parents, however, remain involved in the genesis and perpetuation of their children’s school problems. Handicapped by inflexibility, this kind of family is stable and inclined to deny the educational problem and becomes upset when the severity of the problem diminishes.

In troubled families, the double bind is a frequently encountered interactional pattern that can have devastating consequences for family members enmeshed in it. In essence, the double bind is a covert relationship in which one person has power over the other, who cannot escape. It has two important components. The first consists of paradoxical injunctions in which the less powerful member of the dyad is given conflicting messages either through impossible injunctions, for example, “be spontaneous” or through the nonverbal contradiction of verbal messages, for ex�ample, a parent’s statement ”don’t worry about me” in an anxious tome of voice. The second component occurs over time in which the paradoxical injunctions lead to repetitive behavior patterns. The participants provoke the very behavior from each other that they deplore through incongruous behavior. For example, a mother criticized her silent daughter and encouraged here to express her feelings. When she did, however, the mother broke into tears with, “How can you feel that way after all I have done for you? Then the daughter became silent, eliciting her mother’s criticism again, because she was not speaking.

During therapy these resistant families act like well-drilled teams. When inter�viewed together family members may feel persecuted, become confused, find it hard to think of anything to say, be preoccupied with and silent about the same secret, agree on a fabricated version of a touchy incident, or start arguing with one another and then blame the therapist for upsetting them.

These families typically employ power plays that maintain the status quo. For example, one set of parents nagged their adolescent son into being a “good boy.” To qualify he had to be passive, compliant, infantile, and sexless. When he rebelled his mother histrionically went to bed with intense heart pains, presumably induced by the son, and the father expressed the horror of one who had sired a homicidal son. Another mother coached her son in reading even though the drills ended with both in tears and obviously impeded her son’s motivation to learn. Other parents are so punitive when their children get poor grades that the children retaliate by failing even more.

A specific aim of one family script is to maintain the symptom. As an illustration, one family with a retarded reader convinced their son that he was doing as well as might expected in view or his presumed limited intelligence. They denied clinical reports that his intelligence was normal and disparaged the validity of the tests. Another aim of a family script is to maintain the acceptability of the family’s public image. For example, a family maintained the image of cheerful cooperativeness with no problems apart from their son’s retardation in reading.

Scripts also protect a family’s secrets. For example, when one son began to talk about the “skeleton in the closet” in a family session, the others started conversations on unrelated subjects. If he persisted, they continued to divert the discussion to peripheral topics or tried to talk him out or his opinion.

Some children improve in schoolwork while acquiring a new emotional or behavioral problem. In this maneuver, the children maintain their scapegoat functions in their families and do not have to deal with upsets, which would follow relinquishing their problem roles. Thus they help keep their families from becoming unstable. If the new problem is addressed therapeutically, the members of these families close ranks. They offer carefully reasoned excuses for missing appointments. They accuse therapists of using ineffectual treatment methods and may discontinue therapy. One parent simply said, “I can’t stand any more talk about me. If we have to do that, I would rather have Bryan stay in special ed.”

PARENT EDUCATI0N

Parents benefit from insight into their children’s problems, but insight alone is not enough. They need help in learning to change the emotional climate in the home.

Parent-guidance materials are important means of assisting parents to understand and to cope with a child’s characteristics. Training in parenting skills also is useful. This is particularly needed in developing communication skills through listening, talking with children, and verbal problem solving as employed in Parent Effectiveness Training. Effective communication is basic to the survival of all groups including families. More specific behavioral management techniques have been developed for hyperactive children. Literature is available to help parents play a more significant role in their children’s schoolwork.

Fostering communication between parent and child through parenting education can produce substantial gains in the competencies of children.

Babies and young children with difficult temperamental styles may cause their parents to feel threatened and inadequate with resulting unconscious rejection or scapegoating of the child. A difficult child and threatened parents, therefore, can set in motion a cyclic interaction that makes the child increasingly vulnerable. With older children parents need help in examining their childrearing techniques. Viewing themselves interacting with their children on videotapes can be particularly useful. They may unwittingly reinforce behavior problems through attention to misbehavior, double messages, failing to set limits, ignoring desired behaviors, and inappropriate punishment, all of which result in losing a child’s respect. Although striving for consistency is a laudable objective, still there are times when parental authority must be arbitrary and so acknowledged with children.

To effect a climate of communication, parents can motivate their children by helping them analyze their own behavior and select target behaviors for change. Family meetings are useful for exercising the democratic process, so that each member participates in decision making within appropriately defined limits. When the atmosphere in family meetings is conducive to discussion of problems with openness and dignity, parents can appreciate the importance of changing their own attitudes and listening to their children more carefully. Parent modeling of self-discipline, forgiveness, and a willingness to acknowledge mistakes promotes similar qualities in their children.

Parents can profit from an understanding of sibling relationships in which a mixture of pleasure, affection, hostility, aggression, jealousy, rivalry, and frustration is freely expressed. The sibling relationship can be profoundly important in shaping the development of social skills. At the same time, a younger sibling can languish in the shade of an overbearing older sibling.

Jack C. Westman, M.D., M.S., is professor emeritus of psychiatry at the University of Wisconsin School of Medicine and Public Health. More information about parenting can be found in his book The Complete Idiot’s Guide to Child and Adolescent Psychology, Penguin Press, in bookstores and on amazon.com.

Despite all the fashionable theories of marriage, the narratives and the feminists, the reasons to engage in marriage largely remain the same. True, there have been role reversals and new stereotypes have cropped up. But the biological, physiological and biochemical facts were less amenable to modern criticisms of culture. Men are still men and women are still women in more than one respect.

Men and women marry for the same reasons:

The Sexual Dyad – formed due to sexual attraction and in order to secure a stable, consistent and permanently available source of sexual gratification.

The Economic Dyad – To form a functioning economic unit within which the economic activities of the members of the dyad and of additional entrants will be concentrated. The economic unit generates more wealth than it consumes and the synergy between its members is likely to lead to gains in production and in productivity relative to individual efforts and investment.

The Social Dyad – The members of the couple bond as a result of implicit or explicit, direct, or indirect social pressure. This pressure can manifest itself in numerous forms. In Judaism, a person cannot belong to some religious vocations, unless he is married. This is economic pressure. In most human societies, avowed bachelors are considered to be socially deviant and abnormal. They are condemned by society, ridiculed, shunned and isolated, effectively ex-communicated. Partly to avoid these sanctions and partly to enjoy the warmth provided by conformity and acceptance, couples marry. Today, a myriad of lifestyles is on offer. The old fashioned, nuclear marriage is one of many variants. Children are reared by single parents. Homosexual couples abound. But in all this turbulence, a pattern is discernible : almost 95% of the adult population gets married ultimately. They settle into a two-member arrangement, whether formalized and sanctioned religiously or legally – or not.

The Companionship Dyad – Formed by adults in search of sources of long-term and stable support, emotional warmth, empathy, care, good advice and intimacy. The members of these couples tend to define themselves as each other’s best friends.

It is folk wisdom to state that the first three types of dyad arrangements suffer from instability. Sexual attraction wanes and is replaced by sexual attrition in most cases. This could lead to the adoption of non-conventional sexual behaviour patterns (sexual abstinence, group sex, couple swapping, etc.) – or to recurrent marital infidelity. Economics are not sufficient grounds for a lasting relationship, either. In today’s world, both partners are potentially financially independent. This new found autonomy corrodes the old patriarchal-domineering-disciplinarian pattern of relationship. It is replaced by a more balanced, business like, version with children and the couple’s welfare and life standard as the products.

Marriages based solely on these considerations and motivations are as easy to dismantle and as likely to unravel as is any other business collaboration. Social pressures are a potent maintainer of family cohesiveness and apparent stability. But – being enforced from the outside – it resembles detention rather than a voluntary arrangement, with the same level of happiness to go with it. Moreover, social norms, peer pressure, social conformity – cannot be relied upon to fulfil the roles of stabilizer and shock absorber reliably. Norms change, peer pressure can adversely influence the survival of the marriage (“If all my friends are divorced and apparently content, why shouldn’t I try it, too ?”).

It is only the companionship dyad, which appears to be enduring. Friendships deepen with time. While sex deteriorates, economic motives are reversible or voidable, and social norms are fickle – companionship, like wine, gets better with time. Even when planted on the most desolate land, under the most difficult and insidious circumstances – this obdurate seed sprouts and blossoms. “Matchmaking is done in heaven” goes the old Jewish saying but Jewish matchmakers were not averse to lending the divine process a hand. After closely scrutinizing the background of both candidates – male and female – a marriage was pronounced. In other cultures, marriages were arranged by prospective or actual fathers without asking for the embryos or the toddlers’ consent.

The surprising fact is that arranged marriages last much longer than those, which are, ostensibly, the result of romantic love. Moreover: the longer a couple cohabitates prior to the marriage, the higher the likelihood of divorce. So, romantic love and cohabitation (“getting to know each other better”) are negative precursors and predictors of marital longevity, contrary to commonsense.

Companionship grows out of friction within a formal arrangement, which is devoid of “escape clauses”. In marriages where divorce is not an option (due to prohibitive economic or social costs or because of legal impossibility) – companionship will grudgingly develop and with it contentment, if not happiness. Companionship is the offspring of pity and empathy and shared events and fears and common suffering and the wish to protect and to shield and habit forming. Sex is fire – companionship is old slippers: comfortable, static, useful, warm, secure. We get attached very quickly and very thoroughly to that with which we are in constant touch. This is a reflex that has to do with survival. We attach to other mothers and have our mothers attach to us. In the absence of social interactions, we die younger. We need to bond and to create dependency in others.

The marital cycle is composed of euphorias and dysphorias (which are more of the nature of panic). They are the source of our dynamism in seeking out mates, copulating, coupling (marrying) and reproducing. The source of these changing moods is to be found in the meaning that we attach to our marriages. They constitute the real, irrevocable, irreversible and serious entry into adult society. Previous rites of passage (like the Jewish Bar Mitzvah, the Christian Communion and more exotic rites elsewhere) prepare us only partially to the shock of realizing that we are about to emulate our parents.

During the first years of our lives, we tend to view our parents as omnipotent, omniscient, and omnipresent demigods (or complete gods). Our perception of them, of ourselves and of the world is magical. All are entangled, constantly interacting, identity interchanging entities. Our parents are idealized and, then, as we get disillusioned, they are internalized to become the first and most important among the myriad of inner voices that guide our lives. As we grow up (adolescence) we rebel against our parents (in the final phases of identity formation) and then learn to accept them and to resort to them in times of need. But the primordial gods of our infancy never die, nor do they lie dormant. They lurk in our superego, conducting an incessant dialogue with the other structures of our personality. They constantly criticize and analyse, make suggestions and reproach. The hiss of these voices is the background radiation of our personal big bang.

Thus, to get married, is to become gods, to commit sacrilege, to violate the very existence of our mother and father, to defile the inner sanctum of our formative years. This is a rebellion so momentous, so all encompassing, touching upon the very foundation of our personality – that we shudder in anticipation of the imminent and, no doubt, horrible punishment that awaits us for being so presumptuous and iconoclastic. This, indeed, is the first dysphoria, which accompanies our mental preparations. Preparedness is achieved at a cost of great consternation and the activation of a host of primitive defence mechanisms, which lay dormant hitherto. We deny, we regress, we repress, we project – to no avail. The battle is waged and it is horrific to behold. Luckily, only its echoes reach our consciousness and only in our dreams does it find a fuller (though more symbol laden) expression.

This self-induced panic is the result of a conflict. On the one hand, the person knows that it is absolutely life threatening to remain alone (both biologically and psychologically). A feeling of urgency emerges which propels the person with a great thrust to find a mate. On the other hand, there is this feeling of impending disaster, that he is doing something wrong, that an act of blasphemy and sacrilege is in the making. Getting married is the most terrifying rite of passage. The reaction is to confine oneself to known territories. The terra cognita of one’s neighbourhood, country, language, race, culture, language, background, profession, social stratum, education. The individual defines himself by belonging to these groups. They imbue him with feelings of security and firmness. It is to them that he applies in his quest to find a mate. There, in the confidence of yore, he seeks to find the security of morrow. Solace can be found in familiar grounds. The panicked person can be calmed and restored among his peers and (mental, economic, social) brethren. No wonder that more than 80% of the marriages take place among members of the same social class, profession, race, creed and breed. True: the chances to come across a mate are bigger within these groups and associations – but the more predominant reason is the comfort that it provides. The dysphoria is replaced by an euphoria.

This is the euphoria, which naturally accompanies any triumph in life. Overcoming the panic is such a triumph and not a mean one at that. Subduing the internal tyrants (or guides, depending on the character of the primary objects) of yesteryear qualifies the young adult to become one himself. He cannot become a parent unless and until he eradicates his parents. This is patricide and matricide committed with great trepidation and pain. But the victory is rewarding all the same and it leads to feelings of renewed vigour, new-found optimism, sensations of omnipotence and other traces of magical thinking. The adult is ready to court his mate, woo her, hypnotize her into being his. He is full of the powers of life, of hormones, of energy. He gushes forth, he resounds with the tintinnabulation’s of a better future, his eyes glint, his speech revives. In short, he is immersed in romantic love. Being a suitor is a full time emotional job. The chances of success are enhanced the more mentally and emotionally available is the youth, the less burdened he is with past unresolved conflicts. The more successfully resolved the previous, dysphoric phase – the more vigorous the ensuing euphoric one and the bigger the chances of mating, generation and reproduction.

But our conflicts are never really put to eternal rest. They lie dormant in the waiting. The next anti-climatic dysphoric phase transpires when the attempts to secure (the consent of) a mate are met with success. It is easier and more satisfying to dream. Fighting for a cause is always preferable to the dreariness of materializing it. Mundane routine is the enemy of love and of optimism. This is where all dreams end and harsh reality intrudes with its uncompromising demands. The assent of the future spouse forces the youth to move forward in a path which grows irreversible and ominous as he progresses. The emotional investment is about to acquire economic and social dimensions. The weight is growing heavier, the commitment deeper, the escape remoter, the end inevitable. The person feels trapped, shackled, threatened. His newfound stability flounders. He staggers along a way of no return leading to what looks like a dead end. The strength of these negative emotions depends, to a very large extent, on the parental models of the individual and on the kind of family life that he experienced. The worse the earlier (and only) available example – the mightier the sense of entrapment and resulting paranoia and backlash.

But most people overcome this stage fright and proceed to formalize a relationship. They get married in a religious institution, or in a civil court, or sign a contract, or make their own arrangements. The formality resides in the institutionalization of the relationship – not necessarily in the choice of the legal host. This decision, this leap of faith is the corridor, which leads to the palatial hall of post-nuptial euphoria.

This time the euphoria is mostly a social reaction. The new status (just married) bears a cornucopia of social rewards and incentives, some of them enshrined in legislation. Economic benefits, social approval, familial support, the envious reactions of the younger, the expectations and joys of marriage (freely available sex, children, lack of parental or societal control, newly experienced unrestrained and almost unconstrained freedoms). All these infuse the person with another magical bout of feelings of omnipotence. The control that he exercises over his “lebensraum”, over his spouse, over his life is translated into a fountain of mental forces emanating from the person’s very being. He feels confidence, his self esteem skyrockets, he sets high goals and seriously intends to achieve them. To him, everything is possible, now that he is left to his own devices and is supported by his mate. With luck and the right partner, this frame of mind can last and be prolonged. However, as life’s disappointments accumulate, obstacles mount, the possible sorted out from the improbable and time inexorably passes – the feeling of well being and of willingness to take on the world and its challenges abates. The reserves of energy and determination dwindle. Gradually, the person slides into a dysphoric (even anhedonic or depressed) mood which colours his entire life.

The coloration stops at nothing. The routines of his life, their mundane attributes, the contrast between the glamour of our dreams (however realistically construed) and the reality of our day to day existence – these erode his previous horizon. It tends to shrink and imprison him in what looks like a life sentence. He feels suffocated and in his bitterness and agony, in his fear of entrapment, he lashes at his spouse. She represents to him this dead end situation. Had it not been for this new responsibility – he would not have let his life atrophy thus. Thoughts of breaking loose, of going back to the parental nest, of revoking the arrangements agreed upon begin to frequent the troubled mind and to intrude upon al planning. Dismantling the existing is a frightening prospect. Again, panic sets it. Conflict rears its ugly head. Cognitive dissonance abounds. Inner turmoil leads to irresponsible, self-defeating and self-destructive behaviour. A lot of marriages end here. Those that survive do so because of children.

In his quest for an outlet, a solution, a release of the bottled tensions, an exit from numbing boredom, from professional inertia and “death” – both members of the couple (providing they still possess the minimal wish to “save” the marriage) hit upon the same idea but from different directions. The woman finds it an attractive and efficient way of securing the bonding, fastening the relationship and transforming it into a long-term commitment. Bringing a child to the world is perceived by her to be a “double whammy” (partly because of social and cultural conditioning during the socialization process). On the one hand, it is in all likelihood the glue to cement the hitherto marriage of fun or of convenience. On the other, it is the ultimate manifestation of her femininity. Children are, therefore, brought to the world as an insurance policy against the disintegration of their parents’ relationships. Love and attachment follow later.

The male reaction is more compounded. At first, the child is (at least unconsciously) perceived to be an extension of the state of entrapment and stagnation. The man realizes that a child will only “drag him deeper” into the quagmire. The quicksand characteristics of his life seem to be only amplified by this new entrant. The dysphoria deepens and matures into full-fledged panic. It then subsides and gives way to a sense of awe and wonder. As it increases, it becomes all-pervasive. A psychedelic feeling of being part parent (to the child) and part child (to his own parents) ensues. The birth of the child and his first stages of development only serve to deepen this odd sensation.

Child rearing is a difficult task. It is time and energy consuming. It is emotionally taxing. It denies the parent long obtained achievements and long granted rights (such as privacy or intimacy or self-indulgence or even sleep). It is a full-blown crisis and trauma with potentially the severest consequences. The strain on the relationship of the parents in enormous. They either completely break down – or are revived by the common challenge and hardships. A period of collaboration and reciprocity, of mutual support and increasing love follows. An euphoric phase sets in. Everything else pales besides the little miracle. The child becomes the centre of Narcissistic feelings, of hopes and fears, the heart of an emotional tornado. So much is vested and invested in him and, initially, the child gives so much in return that it blots away the daily problems, tedious procedures, failures, disappointments and aggravations. But this role of his is temporary. The more autonomous a child becomes, the more knowledgeable, the less innocent – the less rewarding, the more frustrating, the sadder the scene, the more dysphoric. The children’s adolescence, the dysfunction of a couple, the members of which grew apart, developed separately and are estranged – set the scenery and pave the way to the next major dysphoria: the midlife crisis.

This, essentially, is a crisis of reckoning, of inventory taking, a disillusionment, a realization and assimilation of one’s mortality. The person looks back and sees how little he has achieved, how short the time left, how unrealistic his expectations were and are, how alienated he is from his society, his country, his culture, his closest, how ill-equipped he is to cope with all this and how irrelevant and unhelpful is marriage is. To him, it is all a fake, a Potemkin village, a facade behind which rot and corruption have consumed his life and corroded his vitality. This seems to be a last chance to recuperate, to recover lost ground, to strike one more time. Aided by others’ youth (a young lover, students, his own children, a young partner or consultant, a start up company) the person tries to recreate his beginnings in a vain effort to make amends, not to commit the same mistakes twice.

This crisis is exacerbated by the “empty nest” syndrome (as children grow up and live the parental home). A major topic of consensus, a catalyst of interaction between the members of the couple thus disappears. The vacuity of the relationship, the gaping hole formed by the termites of a thousand marital discords is revealed. It is the couple’s chance to fill it in with empathy and mutual support. Most fail, however. They discover that they lost faith in their powers to rejuvenate each other. They are suffocated by fumes of grudges, regrets and sorrows. They want out into a fresher (younger) atmosphere. And out they go. Those who do remain, revert to accommodation rather than to love, to co-existence rather to experimentation, to arrangements of convenience rather to revival. It is a sad sight to behold. As biological decay sets in, the couple heads into the ultimate dysphoria: ageing and death.

The primary goal of grief counseling is to deal with the seven most painful feelings; everything else is a derivative of them. Every other painful feeling can be related to those. For example, anger is at the root of resentment and frustration, fear is the source of anxiety and insecurity, and emptiness gives rise to abandonment and loneliness. Shame is a combination of fear and guilt. It’s a fear about what other people may think if they knew.

There are three goals in grief counseling. The first and fundamental goal is to identify and experience the range and intensity of painful feelings that make up grief. We’re going to help the client to identify the feelings cognitively, and then to experience the full range from fear to despair as well as the intensity of the painful feelings related to his loss, or losses.

The second goal is to identify changes or maladaptive behaviour decisions which are related to the loss. This goal is very important in cases of complicated loss, which occurs when the painful feelings have not been dealt with in a healthy way. Instead of being expressed and shared, they’ve been defended against and protected, resulting in unhealthy or maladapted behaviours. By maladaptive we mean ineffective or unworkable or unhealthy behaviour decisions. When we see these behaviours continuing over years, over a long period of time, then we’re seeing this as a complicated bereavement experience of our client.

“Decisions” is an interesting word because the behaviour choices, or ways of coping with the pain, are often done unintentionally or unconsciously, but they are decisions nonetheless. A person can re-decide, can make different decisions about that pain and how to cope with it, how to deal with it.

The third goal of grief counseling is to complete unfinished business, and to say goodbye in order to say hello. It’s difficult to say hello to new life experiences until we say goodbye to old painful ones, and by goodbye we mean letting go. Saying goodbye, and letting go, and learning acceptance, which is a commonly used term, all mean the same thing.

Saying goodbye really encompasses all three objectives for grief counseling. A person hasn’t completely grieved, or said goodbye, or let go, until he has worked through the pain, identified and changed the behaviour decisions, and finished his unfinished business.

You can see that these goals correspond to the counseling process as we’ve been discussing it. It’s simply a reiteration of what we’ve been talking about. As we’re discussing loss and grief, I’d like for you to be thinking about your own losses. These could be deaths of loved ones, break-up of relationships, loss of parental caring and relationships are the major ones, the most difficult ones.

Once you’ve identified a loss and the person can express the sadness, how often do you go back to that loss? Maybe you think a person could experience those feelings surrounding a loss indefinitely just by putting himself back in that place again. How do you know when enough is enough?

There are two different views. The cognitive school says you don’t really get rid of the pain, you just know all about it. You become so familiar with it that it no longer has power over you. And the only way to know all about it is to experience it. There’s no other way. So there is a point at which cognitive therapy has to include grieving, otherwise there’s no true knowledge of the pain.

The other school of thought which is represented, for example, by people who use psychodrama a lot, is that when you express the pain it’s possible to release it, and to purge yourself of it. It may take a long time for that catharsis to be complete, but eventually the pain will be completely gone.

I tend to think it’s a combination of both. There is a catharsis effect, and some of the pain is released, but then there is also the cognitive aspect of knowing about the intensity of the pain, that takes the power away from it. I’m no longer frightened of the pain. I know about it and I’ve accepted it as mine, and as okay. I have embraced the pain.

INTERVENTIONS FOR THE EMOTIONS OF GRIEF

Now let’s go on to looking at the painful feelings. The first goal of grief counseling is to identify and experience the range and intensity of painful feelings. It’s going to be important for us to review these feelings and to suggest some therapeutic interventions for working with the grieving person. We also need to realize what the fear of painful feelings is about.

Imagine a successful executive of a corporation who has never experienced any tragedy in his life, any major loss. He has a wife and three kids and he gets a phone call that one of his children, a six or seven year old child, has just been hit by a truck and killed in front of the house. The child came home from school and crossed the road in front of a gravel truck coming from a nearby construction site, and was killed. Now this man has a lot of responsibility to provide for his family and to keep his company going, and since he has experienced a tragic loss he goes for counseling. It’s very difficult for him to engage his pain, because he’s afraid of what?

He’s afraid of falling apart and of not being able to get on with all of the things he has to do. He needs to maintain the image of the corporate person. And he’s been working on being able to do this for many years and to continue with his heavy responsibilities. So not having experienced intense grief before, he doesn’t know that it’s not going to cause him to fall apart.

In fact he doesn’t realize that if he doesn’t allow himself to grieve, then he’s going to fall apart. It’s going to be just the opposite of what he’s afraid of. So we need to help that person get past the fear, and the way to do that is to encourage him to talk about the fear, to validate the fear, to reflect how scary it may be, and then invite him just to say a little bit about it.

Fear

I find this is a very effective approach when working with the very blocked, resistant client: invite him to say just a little bit about the little bit of fear that he may have. And once he feels supported with that, then he can go on to another painful feeling.

A gradual approach to the feared object is fundamental to working with fear. Remember that whenever there is fear, there is resistance, defenses. So it is important to go slowly, invite the person to say what the fear is about and after he has disclosed, ask him what it was like to talk about that. Then invite him to say a little more.

Whenever, there is disclosure of difficult, painful experience, be sure to process the process by saying, “What was it like talking about that? Is it OK?” This allows the client to control the pace and amount of disclosure and to validate the process and to maintain his sense of safety.

Sometimes the fear is about feeling so much of the pain, he will become depressed or so sad that he will never stop crying. So we can say, “I wonder if you are afraid that if you start crying you may never stop, and you will fill the whole world with your tears.” This can free up the sadness, and he will discover that the crying does end and he survived it. This will help the healing, and life will be easier and less sad.

Anger

Some grieving people find it easier to access anger than their sadness. They’ll use their anger to defend against their sadness. They feel strong with anger but weak and vulnerable with sadness. Generally the person who finds it easier to access anger in grief has an aggressive personality. They are usually outspoken, direct, and opinionated. In working with the very angry, grieving client, we can validate that anger for as long as he needs it to be validated. Draw it out and encourage him to express it, entitle him to that anger.

If we’re able to validate or support a person’s anger, what feeling comes next? The sadness will come out more easily if the anger has been properly supported. Now with the passive individual, who accesses sadness more easily, we need to help him express the anger. The passive individual feels guilty about anger and is afraid of its destructiveness. So to reach for anger we can use the word “cheated,” or another word that the person feels safer with.

So we can say, “I wonder if you feel a little cheated? Your husband has died, you expected you’d be able to retire together, you were looking forward to that. And now he’s gone. I wonder if you feel just a little bit cheated about that?” And sometimes what I find is that if I minimize a feeling and use the word cheated with that individual, she’ll maximize and say, “Yes, I feel really cheated.” And I’ll say, “Go on and say more about being cheated.” In fact she is talking about her anger, but she is just not using that word.

Try to find words that don’t offend the client or that don’t trigger the guilt or fear around anger. Try to use other approaches and other words. Here are some other approaches.

You can say things like, “What are some ‘why’ questions? If you were to ask ‘why’ questions about the death of your father, or the death or your child, what would they be?” What are some of those ‘why’ questions? Why did you die? Why him? Why did he leave me? Why not me? Why did God let this happen? Often the anger is directed at God. So then I’ll say, “What’s the feeling that goes with that why question? Fear, anger, guilt, sadness, emptiness?”

If it was a child the client may ask why a child died. Why not an older person? Why not someone who’d lived a full life? Why a child? Anger is what goes with that question; the outrage, the sense of injustice, the unfairness. Sometimes your client will come up with anger. Then you can invite him to say more about the anger. And you can validate it, support it.

Another thing we can do is say, “Talk about the lost hopes and dreams.” Lost hopes and dreams are about being cheated because those hopes and dreams can’t be fulfilled now that this death and this loss has occurred. There’s a sense of feeling cheated about that. Another thing I may do to draw anger is to design a statement for my client to repeat. I may design a why question or a blaming statement.

For example in the case of an abusive parent, in working with loss of parental caring and closeness, I may suggest the statement, “You didn’t care about anyone but yourself. You didn’t care about me, all you cared about was the bottle.” Try on that statement. I may say it without any affect in my voice.

You can tailor a statement, invite your client to repeat it, and then reach for a feeling. “What’s it like saying that? Does that fit? What feelings come up when you say that? What choice words do you have for this man?” Go for choice words or strong words, if your client has them in his vocabulary. For the type of client that has choice words available to him, ask him what some choice words may be. The passive client may not have choice words in his vocabulary. Some of these words could possibly be very coarse and powerful.

We are facilitating the expression of emotion through name-calling, I’m talking here about the client who has been severely abused, mistreated. We need to have a way to vent that anger in a therapeutic setting, not face to face with the abuser. So you don’t really want to escalate it but you want to allow this person to feel that it’s okay to feel angry.

Sometimes anger is directed toward the counselor as a defense. When a client becomes very resistant and begins to struggle with the counselor, we can say, “So I wonder if hanging on to the struggle is a way of not getting on with your healing.” When he acknowledges this, direct him, “Now talk about what’s behind the struggle, talk about what’s hard to talk about, what’s hard to face.”

Sadness

When I’m starting to bring out anger and sadness with a client, I may also say, “I wonder if you’re using that anger to defend against another feeling.” Or “I wonder if that anger is easier than the sadness.” Or if a client identifies both anger and sadness I’ll say, “Which of those two feelings is easier for you to express?”

She may have identified anger as a primary feeling, and I may reach for a little sadness. She may have owned a little sadness, and then I would say, “Which one is easier for you to feel?” And whichever one she chooses I’ll invite her to talk about the opposite one because it’s the one she doesn’t want to talk about that needs to be worked through. The key to a person’s progress is to invite him to explore and integrate whatever is most difficult.

Other ways to get to sadness is to say the following:

“Say his name.” The name of the loved one may be loaded with sadness and remains unspoken until you invite it.

“Talk about a happy memory.” The happy memory brings up a sense of loss and sadness.

“Talk about the last time you saw him.” The last memory may be of the death or of regrets and sadness about this.

“What do you see as your talk? It’s as if you are looking at something.” Tapping into mental images may be associated with sadness because the past is being re-lived in the present.

“You will never see his face again.” The realization about the finality of the death is often very sad but true.

“Have you said good-bye to him?” This brings up sadness about the finality of the loss and can be key to letting go.

While observing the client’s emotional response, take note of keywords and phrases immediately preceding the sadness, then repeat these words at an opportune time to facilitate grief. For example, a client grieves when describing how her son was killed by a “power truck.” Later, I simply said, “There was a power truck,” and the client cried.

Remember to always process the process after a client has finished crying, by saying, “What’s its like talking about this and feeling these things? Is it OK to cry?” And if she says it hurts so much say, “It’s normal to feel that with what you’ve been through. You loved him.”

Guilt

Guilt is one of the primary reasons that people develop very maladaptive behaviours. A person who feels very guilty doesn’t believe that he deserves happiness, and so what does he think he think he deserves? Punishment. Punishment goes with guilt, so I may want to explore with the person how much guilt he feels? Maybe a little bit, a lot? This is the same technique I may use exploring any feeling. How much anger do you feel? A little bit, a lot, a medium amount? I want to gauge how much of that feeling they are aware of inside.

If they feel a lot of guilt, or they identify a feeling of guilt I’m going to say, “I wonder if you’re aware of how you may be punishing yourself.”

And then I’ll say what some people do. “Sometimes when people feel guilty they won’t let themselves be happy, they’ll be depressed, they’ll be stuck in their life. They won’t let themselves get on with their life. They won’t let themselves experience enjoyment, they won’t let themselves be close to people, they won’t let themselves really welcome the challenges and opportunities that life has to offer. And I wonder if you’re aware of how you may be punishing yourself in some small way?”

A helpful approach is to use exaggeration: “I wonder if you will give yourself a life sentence.” When the client considers this, they have a chance to realize what he may have done and decide to let go of the self-punishment. “What will you do differently? Can you let go of that?” and “What would (your loved one) say?”

Use of minimizing and exaggeration

So again use that minimizing technique, because it’s easier for people to think of small ways sometimes and then that opens up other areas of awareness. So a person will choose and then I’ll say, “I wonder if you’re going to give yourself a life sentence?” That’s making use of exaggeration. In other words, take that metaphor to its ultimate conclusion, or to it’s extreme, which could be something like a life sentence of punishment by means of depression. For example, I had a client who lived a rebellious life, and then his mother suddenly died of a heart attack. He blamed himself for his mother’s death and he became chronically depressed after that for a number of years. When I saw him in treatment I explored the guilt with him, and I said, “I wonder how you may punish yourself? I wonder if maybe depression is a way you may do that?” And he acknowledged it. And he went on saying that he didn’t deserve to be happy. He felt that his life style was a cause of his mother’s death. And so I said, “I wonder if you’re going to give yourself a life sentence?” And he stopped and the wheels were turning and he made a new decision. He pulled back from the guilt.

With the extreme conclusion or exaggeration intervention, a person will pull back from the exaggerated possibility. He’ll say, “No, I’m not going to take it to that extent.” This client started making real changes, real improvements in his direction. When people feel really guilty, they won’t allow themselves to get on with their grieving. They’ll remain stuck in it, and that’s their unconscious form of punishment.

Hanging on or letting go

Sometimes people won’t let themselves work through their sadness and their anger, or other painful feelings, because hanging on to the guilt is a way of hanging on to the person who died. Sometimes I’ll put it to a client that way. I’ll say, “I wonder if hanging on to that guilt may be a way of hanging on to Mom?” And some times they don’t realize it, they haven’t thought of it in those terms. When you put it that way it helps them to decide not to hang on.

I’ve heard clients say that: “I don’t want to hang on any more.” That implies letting go of the guilt. You can use that with anger: “I wonder if hanging on to that anger is a way of hanging on to the man you divorced? Hanging on to the fight may be a way of hanging on to your ex-husband. Hanging on to the fight may be a way of hanging on to Dad.”

You can move people forward by saying, “It’s not easy to let go. It’s not something you need to hurry.” What you often hear is, “How do you let go?” and I say, “By doing exactly what you’re doing today. Talking about your feelings, putting it into words, by doing exactly what you’re doing and I encourage you to keep doing that. What’s it like doing that today, talking about your pain?” And they’ll say, “It’s tough.”

I mentioned earlier that some people use anger to cover sadness and others use sadness to cover anger. So sadness is not necessarily the core feeling, although often for the person who’s very angry, it’s important for him to get to his sadness.

For the person who’s very sad, especially if he appears to be stuck in sadness over a long period of time, weeks, months, or maybe years, maybe it’s because it’s because he hasn’t dealt with the anger, or he hasn’t dealt with the guilt, or both.

Emptiness

So then we come to emptiness. Emptiness is something a person may feel constantly. But sometimes a person will fill the emptiness, or attempt to fill that empty feeling or that void with the other painful feelings. It’s easier to feel anger than that agonizing emptiness or that sense of the void, that abandonment, that loneliness.

Sometimes, early on in grief counseling, that person may identify feeling empty, and the way I may work with that is to say, “What goes into that emptiness? Would it be empty sad, empty angry, empty frightened, empty guilty, empty what?” I’ll associate another feeling with the emptiness.

And I may work with the emptiness on its own, and just invite the person to talk about the emptiness. She may talk about a loved one she lost, who had been in her life at the dinner table, or in bed beside her if it’s a partner, a spouse. The spouse came to the door at the same time on schedule for so many years, and now that person is gone and so there are empty spaces at the table, in the bedroom, at the door.

When a child dies there is tremendous emptiness because that child has occupied so much of the parents’ time, and has contributed so much to the noise level. The child leaves a deafening silence that’s very agonizing. We need to help a person identify what the emptiness is about and then validate that.

Now the emptiness may become more apparent to a person as she gets support and is able to put these other painful feelings, the anger or sadness, into words. As she’s letting go of that anger or sadness, the emptiness may still be there and it may be even more obvious to the person. And most especially, I find that clients report feeling empty when I invite them to talk about letting go or saying goodbye to the loved one.

For example, I sometimes use the empty chair to invite a person to talk to a loved one about saying goodbye, and I then explore the feelings that he’s left with. I say, “What’s it like, what are you feeling inside as you say goodbye and as you talk about saying goodbye to your father or your child? What feelings come up? Fear, anger, guilt, emptiness, despair?” And nine times out of ten they choose emptiness because that’s what’s left if you’re going to say goodbye to somebody.

Now if a person has done a fair amount of grieving, I’ll work with that emptiness in a therapeutic way by saying, “Maybe you’re at a kind of crossroads in your grief. You can either fill that emptiness with the old pain, your old ways of being stuck and not getting on with your life, not letting yourself be close to other people, or you can begin to fill that emptiness with the challenges that life has to offer, taking risks to get close, allowing yourself to enjoy pleasurable experiences in life. Which way do you think you’ll go on this crossroad?”

That’s a cognitive technique that allows clients to make a conscious decision about what they’re going to do or which way they’re going to go. This is transition toward reconstruction of life and saying hello to new people and experiences.

Seeing the hidden loss

If there was emotional distance, a loss of bonding, or if the lost person was experienced as angry, the grief may be buried and be more about the loss of closeness when the person was alive or prior to the loss.

A woman married a man who disclosed to her after two or three years of marriage that he was homosexual, and then he ended the relationship. She didn’t appear to go through any grieving process at all when it actually ended. She went back to work the next day and two months later she met another man. She got married and had kids, and I’m not aware of her going through much grief. Why? Because the marriage was the loss not the ending of the marriage. She grieved when she first learned he was gay; she was angry, sad; felt guilt, low self-worth, emptiness.

Grief will only be experienced as an intense kind of experience if there’s been bonding. If there hasn’t been significant emotional bonding, it’s not as much of a loss. If he was homosexual it’s understandable that there may not have been much intimacy, or closeness, or bonding. It may have been some other kind of relationship, more like a brother and sister rather than husband and wife. So it has to do with how much is invested.

A woman came up to me after a talk I had given and said that when her mother died she didn’t grieve. And she wanted to know why, because other people grieve. She wondered why she wasn’t upset. I asked her, “Were you close to your mother?” and she said “No.” She had never been close all those years. And I said, “I wonder what feelings come up inside you when you think about all those years of not being close to your mother?” That’s when the tears welled up in her eyes. That’s what her grief was about. It wasn’t about her mother’s death. It was about the loss of closeness during her lifetime.

Low self-worth

A person may feel low self-worth, especially if he is experiencing feelings of guilt, because when a person feels very guilty he doesn’t feel worthwhile, he doesn’t feel he deserves to go on living.

A person may also experience low self-worth if he comes from a dysfunctional family and now has experienced a tragic death of a loved one. He may feel as though he didn’t really deserve to have that person be alive for him. Low self-worth sometimes happens when people bargain, for example with God, over the life of the person who died. So you may hear about a person saying, “I’m really the one who should die. Don’t let that child die. Take me, God.” So in that kind of bargaining the implied message is, “I’m not as worthwhile as the child.” A person may then become very depressed, and isolate or deprive himself of enjoyment in life because he doesn’t feel worthwhile or deserving.

In cases of sexual abuse, low self-worth is connected to shame or to feeling dirty. What do you do with something if it’s dirty or worthless? You throw it away. That’s another kind of loss that we haven’t yet talked about. Sexual abuse and assault is a very significant loss. Feeling dirty or feeling shame is closely related to that and leads to self-abuse by choosing unhealthy relationships and lifestyle or behaviours that distance from others, such as obesity or aggression.

Despair

Despair and hopelessness are the sum total of these other painful feelings, and as a person is engaging in the grief process and getting support and validation, often that despair will diminish. The despair may appear early on along with fear, but as the safety of the counseling relationship increases and the therapeutic alliance improves, despair sometimes diminishes along with the fear.

Despair often goes with confusion. A person may have a lot of painful feelings inside that he hasn’t identified, especially early in the grief process. He feels despair because he has the intensity of all that pain but he hasn’t been able to sort it out. So as you work with him throughout the process and identify the distinct feelings and help him work through them, the confusion and the despair diminish.

Prior loss affecting a current loss

If a person has suffered significant losses throughout her lifetime, is the coping process easier for her? It depends on how she has dealt with those previous losses. If she has coped with her previous losses in an unhealthy way by burying feelings, or by dumping feelings, or by distancing herself from others, that can become a pattern.

For example, some people won’t say goodbye; they’ll just leave and you’ll wonder where they went. And it may be that that’s related to their style of hanging on or their style of dealing with loss and separation from an earlier experience in life. Sometimes when a person experiences a tragic loss it will bring up their previous losses. And if there seems to be difficulty establishing and maintaining intimate relationships and getting on with life goals, it may be due to unfinished business with a previous loss.

Daniel Keeran, MSW, has been a professional counselor and therapist for 30 years. He has provided counseling and training to thousands of professionals and the public through his private practice, seminars, and online training courses.